Resources incident investigation

In addition to incident reporting systems, root cause analysis techniques can be used to evaluate the causes of serious incidents where resources are usually available for in-depth investigations. A practical example of root cause investigation methods is provided in Chapter 7. 

This section describes the formal approval and acceptance method for the report and where the final report and any supporting documentation will be maintained. It may state the company document retention policy for incident investigation or refer to another resource to determine how information must be kept. 

External resources may he needed if the incident investigation work exceeds site capahilities. These resources could include corporate personnel or experts from outside the company. (The team leader may also he external if the incident is major since the leader s independence sets the tone for the investigation.) Company business unit leaders should confer with the team leader to determine whether external assistance is recommended. Factors to consider include significant offsite consequences such as environmental impact or product quality concerns. A team of trained specialists should formally investigate any process incident that could significantly affect the business. At the lower end of the scale, if a near miss or minor incident occurs that has no potential for significant consequences, local supervision or front-line personnel normally may perform the investigation without outside assistance. 

Use shared external learnings to determine what others have successfully used. Information sources mentioned in Section 4.5.2 are excellent resources for information, such as incident investigation learnings and successful use of various metrics. 

A careful analysis of the findings from a facility s incident investigations can help determine if cost-cutting measures may have gone too far. For example, if many incidents result from people not having sufficient training, then maybe the Training Department was slimmed down too far. Alternatively, if those incidents result from failed equipment items then the Maintenance Department needs to be provided with more resources. 

Because of the variances in safety cultures and the resources available, it is folly to suggest that an incident investigation system could be crafted that would universally apply in all organizations. Guidance is given for a safety professional to assess that which is attainable and to draft an incident investigation system that relates realistically to organizational culture and sophistication. 

I emphasize that this Reference For Causal Factors and Corrective Actions is presented as a resource for the designer of an incident investigation system, with the assumption that the designer would make revisions in it to suit organizational needs. 

Designer Incident Investigation is to help safety personnel craft practical and realistic incident investigation systems, after considering the resources available and organizational sophistication. 

Provide materials and resources to assist a safety professional in crafting an incident investigation procedure suitable to an organization s culture. 

A review of the forementioned documents will provide an inexpensive and valuable education. Now, to extend the resource list, five books on incident investigation and root causal factor identification and analysis and one Manual are referenced. There are other resources. 

Analyses made of incident investigation reports can be a valuable resource in selecting and prioritizing leading indicators. If the... 

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